The dietary intake of a group of vegetarian children aged 7-11 years compared with matched omnivores

Plant-Based Diets in Children: Secular Trends, Health Outcomes, and a Roadmap for Urgent Practice Recommendations and Research-A Systematic Review

People are increasingly encouraged to reduce animal food consumption and shift towards plant-based diets; however, the implications for children's health are unclear. In this narrative review of research in high-income settings, we summarize evidence on the increasing consumption of plant-based diets in children and update an earlier systematic review regarding their associations with children's health outcomes. The evidence indicates that vegan, but not vegetarian, diets can restrict growth relative to omnivorous children and increase the risk of being stunted and underweight, although the percentage affected is relatively small. Bone mineral content is reduced in vegetarian and, in particular, vegan children, compared to omnivores. Both vegetarian and vegan children who do not use vitamin B12 supplements manifest with B12 deficiency; however, supplementation rectifies this problem. Both vegetarians and vegans have lower concentrations of 25(OH)D if unsupplemented, and lower body iron stores, but usually have normal iron metabolism markers. Both groups are at risk of iodine deficiency, and this might affect thyroid health. Children consuming a vegan diet have a more favorable lipid profile than omnivorous children; however, the results for a vegetarian diet are inconsistent and vary by outcome. Based on the same scientific evidence, national and international dietary recommendations are heterogeneous, with some countries supporting plant-based diets among infants, children, and adolescents, and others discouraging them. We offer a research roadmap, highlighting what is needed to provide adequate evidence to harmonize dietary recommendations for plant-based diets in children. A number of measures should urgently be introduced at international and national levels to improve the safety of their use in children.

The potential for the use of leghemoglobin and plant ferritin as sources of iron

Iron is an essential component for the body, but it is also a major cause for the development of many diseases such as cancer, cardiovascular diseases, and autoimmune diseases. It has been suggested that a diet rich in meat products, especially red meat and highly processed products, constitute a nutritional model that increases the risk of developing. In this context, it is indicated that people on an elimination diet (vegetarians and vegans) may be at risk of deficiencies in iron, because this micronutrient is found mainly in foods of animal origin and has lower bioavailability in plant foods. This article reviews the knowledge on the use of leghemoglobin and plant ferritin as sources of iron and discusses their potential for use in vegetarian and vegan diets.

Vegetarian diets and diets which restrict animal-source foods during childhood in high-income countries

Increasing numbers of populations in the West are restricting their intake of meat and other animal products for reasons relating to health or ethics; in many countries, these restrictions are already common for cultural, religious, or socio-economic reasons. By following their parent's diet, children are exposed in parallel. This narrative review aims at assessing current data regarding vegetarian diets in children from birth to 18 years of age, which include, by increasing degree of restriction, flexitarian, lacto-ovo-vegetarian, lacto-vegetarian, pescatarian, vegan and macrobiotic diets. The 202 references include 45 studies in children. The more restrictive the diet and the younger the child, the greater the risk of nutritional deficiency. Of particular concern are vitamin B12, iron, zinc, calcium, n-3 long-chain polyunsaturated fatty acids, and protein and energy intake, especially in pregnant and nursing women, infants and young children. Providing an adequate lacto-ovo-vegetarian diet is relatively easy, whereas the maintenance of more restrictive diets may be challenging. The benefits and risks of vegetarian diets in adults are relatively well documented, but data for children are scarce. Vegan and macrobiotic diets should be discouraged in pregnant and lactating mothers as well as in young children, who, otherwise, should pay careful attention to ensuring nutritional adequacy, blood testing and appropriate supplementation. The health consequences of a chosen diet should be discussed with parents and adolescents to ensure the best possible adherence to advice and prescriptions. There is a need for well conducted studies in children but also for better knowledge of nutrition in healthcare professionals.Abbreviations: ALA: α-linolenic acid; ARA: arachidonic acid; ASF: animal source foods; BMC: bone mineral content; BMD: bone mineral density; DHA: docosahexaenoic acid; DRV: dietary reference value; EPA: eicosapentaenoic acid; FLD: flexitarian diet; LA: linoleic acid; LC-PUFA: long-chain polyunsaturated fatty acids; LOVD: lacto-ovo-vegetarian diet; LVD: lacto-vegetarian diet; MAD: macrobiotic diet; OMD: omnivorous diet; PSF: plant-source foods; SFA: saturated fatty acids; VGD: vegetarian diets; VND: vegan diet.

Risk Assessment of Micronutrients Deficiency in Vegetarian or Vegan Children: Not So Obvious

Vegetarian diets have gained in popularity worldwide and therefore an increasing number of children may be exposed to the resulting nutritional consequences. Among them, the risk of micronutrient shortfall is particularly of concern. This narrative review aims to assess and discuss the relevance of micronutrient deficiency risk based on the available data. It mainly draws attention to iron, zinc, iodine, and vitamins B12 and D intake. Diets that are more restrictive in animal source foods, such as vegan diets, have a greater likelihood of nutritional deficiencies. However, the actual risk of micronutrient deficiency in vegetarian children is relatively difficult to assert based on the limitations of evidence due to the lack of well-designed studies. The risk of vitamin B12 deficiency must be considered in newborns from vegan or macrobiotic mothers and children with the most restrictive diet, as well as the risk of iron, zinc, and iodine deficiency, possibly by performing the appropriate tests. A lacto-ovo-vegetarian diet exposes a low risk if it uses a very varied diet with a sufficient intake of dairy products. Vegan and macrobiotic diets should be avoided during pregnancy and childhood. There is a need for education and nutrition guidance and the need for supplementation should be assessed individually.

Intake of micronutrients and fatty acids of vegetarian, vegan, and omnivorous children (1-3 years) in Germany (VeChi Diet Study)

Purpose

There is an ongoing debate whether vegetarian (VG) and especially vegan (VN) diets are nutritionally adequate in early childhood. Hence, the Vegetarian and Vegan Children Study (VeChi Diet Study) aimed to assess the food and nutrient intake of VG and VN infants.

Methods

The study examined the diets of 1–3-year-old VG, VN, and omnivorous (OM) children (n = 430). Dietary intake was assessed via a 3-day weighed dietary record and compared between groups using ANCOVA. Lifestyle data were collected using a questionnaire. Here, the results of micronutrient and fatty acid intakes are presented.

Results

Most nutrient intakes (with and without supplements) differed significantly between VN children and the two other groups, with a more favourable overall micronutrient intake in VN, followed by VG children, [e.g., the highest intake of vitamin E (8.3 mg/d vs. VG 7.4 mg/d and OM 5.1 mg/d), vitamin B₁ (569 µg/d vs. VG 513 µg/d and OM 481 µg/d), folate (143 µg/d vs. VG 116 µg/d and OM 108 µg/d), magnesium (241 mg/d vs. VG 188 mg/d and OM 164 mg/d), and iron (8.9 mg/d vs. VG 7.3 mg/d and OM 6.0 mg/d)] as well as fat quality [highest intake of polyunsaturated fatty acids (8.7 E% vs. VG 6.9 E% and OM 4.5 E%) and lowest intake of saturated fatty acids (9.1 E% vs. VG 11.9 E% and OM 14.0 E%)]. In contrast, OM children had the highest intake of vitamin B₂ (639 µg/d vs. VG 461 µg/d and VN 429 µg/d), calcium (445 mg/d vs. VG 399 mg/d and VN 320 mg/d), iodine (47 µg/d vs. VG 33 µg/d and VN 31 µg/d), and DHA (35.4 mg/d vs. VG 16.6 mg/d and VN 18.4 mg/d). Without supplementation, OM children had the highest average vitamin B₁₂ intake (1.5 µg/d vs. VG 0.6 µg/d and VN 0.2 µg/d), whereas VN children had the highest average vitamin B₁₂ intake with supplementation (73.8 µg/d vs. VG 1.3 µg/d and OM 1.7 µg/d). Without supplementation, none of the groups’ median intakes met the harmonised Average Requirement (h-AR) for vitamin D and iodine. Moreover, VG and VN children did not achieve h-ARs for vitamin B₂, vitamin B₁₂, and iron—if a low absorption of iron is anticipated; VN children also did not do so for calcium.

Conclusion

In early childhood, VN and VG diets can provide most micronutrients in desirable amounts and a preferable fat quality compared to an OM diet. Special focus should be paid to (potentially) critical nutrients, particularly vitamin D, iodine, and DHA for all children regardless of diet, as well as vitamin B₂, vitamin B₁₂, calcium, and iron for VG and VN children.

Trail registration

This study was registered with the German Clinical Trials Register (DRKS00010982) on (September 2, 2016).

Supplementary Information

The online version contains supplementary material available at 10.1007/s00394-021-02753-3.

Complementary feeding: new styles versus old myths

Early life feeding habits may potentially alter future metabolic programming and body composition. Complementary feeding is the period of time when infants introduce food different from milk in their diet, together with a gradual reduction of the intake of milk (either breast milk or formula), to finally acquire the diet model of their family. This period is important in the transition of the infant from milk feeding to family foods, and is necessary for both nutritional and developmental reasons. The timing for introducing complementary foods and the method of feeding have changed over time. Available literature data show increasing interest and concerns about the impact of complementary feeding timing and modality on the onset of later non-communicable disorders, such as overweight and obesity, allergic diseases, celiac disease, or diabetes. While international scientific guidelines on complementary feeding have been published, many baby food companies' websites, blogs, and books, in most European countries exist. The aim of this manuscript is to look over current recommendations, and to revise "old myths." The adoption of an adequate weaning method is a cornerstone in the development of life-long health status. A correct strategy could reduce the risk of feeding disorders and other health problems later in life.

Plant-based diets for children as a means of improving adult cardiometabolic health

Cardiovascular disease (CVD) is the largest contributor to global mortality, and this trend is expected to continue. Although mortality rates have been falling, adverse developments in obesity and diabetes threaten to reverse this. It has been estimated that the only viable strategy to reduce the epidemic is to focus on population-wide risk factor reduction. Primordial prevention, a strategy aimed at avoiding the development of risk factors before the disease onset, has been shown to reduce the CVD epidemic substantially. Plant-based diets appear beneficial for prevention of cardiometabolic diseases, with adult vegetarians and vegans having lower CVD risk than omnivores. Atherosclerosis starts in childhood and progresses in relation to classical CVD risk factors, which, along with dietary habits, track to adulthood. Based on this evidence, it is proposed that plant-based diets in childhood could promote cardiometabolic health in adults and thereby reduce CVD and promote longevity and health. However, the need for additional research to establish the safety of predominantly or exclusively plant-based diets in children is noted.

Beyond Meat: A Comparison of the Dietary Intakes of Vegetarian and Non-vegetarian Adolescents

Dietary intake of adult vegetarians from large prospective studies has been well-characterized but is rarely reported in vegetarian adolescents. Our objective was to describe and compare the dietary intake of vegetarian adolescents with their non-vegetarian counterparts in a population known to espouse healthy living. Adolescents (n = 534) aged 12–18 years old from middle and high schools near major Adventist universities in Michigan and Southern California provided dietary, demographic, and anthropometric data. Dietary intake was measured with a validated 151-item self-administered web-based food frequency questionnaire; weight and height were measured during school visits. Vegetarian was defined as the combined intake of meat, meat derivatives, poultry, and fish of <1 serving per week. Descriptive statistics and ANCOVA were used to compare the intake of vegetarians and non-vegetarians. Vegetarians significantly ate more fruits, vegetables, and other plant-based foods, but significantly less foods of animal origin, sugar-sweetened beverages, and coffee/tea compared to non-vegetarians. Vegetarians had significantly higher intakes of carbohydrates and total protein but lower intakes of fats, animal protein, and zinc compared to their counterparts. A majority (75% or more) of both groups met the 2015 Dietary Guidelines' age-and-gender-specific recommendations for most nutrients but only 16–18% of vegetarians/non-vegetarians did not exceed the upper limit for sodium. More vegetarians (49%) than non-vegetarians (25%) had <10% of their caloric intake from SFA. More than 90% of both groups met dairy recommendations, but greater proportions of vegetarians met recommendations for vegetables, fruits, nuts/soy products, and legumes than non-vegetarians. Of the non-vegetarians, only 7% and 44% met the fish and meats/poultry/eggs recommendation, respectively, which none of the vegetarians met. Compared to the general US adolescent population, both diet groups ate more fruits, vegetables, dairy and protein foods, and also consumed more micronutrients but less macronutrients. Overall, vegetarian adolescents have a more favorable dietary intake profile than non-vegetarians, but both vegetarians and non-vegetarians in this study population have a more adequate diet than the general US adolescent population. The influence of the Adventist plant-based diet culture that is translated both at home and at school is evident in our findings.

Bone status and adipokine levels in children on vegetarian and omnivorous diets

BACKGROUND & AIMS

Measurements of bone mineral density (BMD) reflect bone status but not the dynamics of bone turnover. Biochemical markers, which show global skeletal activity, were validated for the assessment of bone formation and resorption processes. Adipokines also play a significant role in the regulation of bone metabolism.

OBJECTIVE

To assess body composition, bone mineral density, bone turnover markers and adipokine levels in relation to vegetarian and omnivorous diets.

METHODS

The study included 53 vegetarian and 53 omnivorous prepubertal healthy children matched for age and sex (median age 7.0 years). Body composition and BMD were assessed by dual-energy X-ray absorptiometry. 25-hydroxyvitamin D and parathormone levels were measured by chemiluminescence method. Serum carboxy-terminal propeptide of type I collagen (CICP), total osteocalcin (OC) and its forms carboxylated (c-OC) and undercarboxylated (uc-OC), C-terminal cross-linking telopeptide of collagen type I (CTX), leptin and adiponectin levels were determined using immunoenzymatic assays.

RESULTS

Both groups of children were comparable in terms of body composition, except for the percentage of fat mass, which was lower (19.24 vs. 21.77%, p = 0.018) in vegetarians. Mean values of total BMD z-score and lumbar spine BMD z-score were lower (-0.583 vs. -0.194, p = 0.009 and -0.877 vs. -0.496, p = 0.019, respectively) in vegetarians compared with omnivores. Serum leptin level was about 2-fold lower (1.39 vs. 2.94 ng/mL, p < 0.001) in vegetarians, however, adiponectin concentration was similar in both groups. Vegetarians had similar concentration of 25-hydroxyvitamin D, but higher parathormone (40.8 vs. 32.1 pg/mL, p = 0.015) and CTX (1.94 vs. 1.76 ng/mL, p = 0.077) levels than omnivores. Total osteocalcin and CICP concentrations were comparable in both groups, however, c-OC/uc-OC ratio was higher (1.43 vs. 1.04 ng/mL, p < 0.05) in vegetarians. We found positive correlation between c-OC and nutritional parameters adjusted for total energy intake (plant protein, phosphorus, magnesium and fiber intakes) in vegetarian children.

CONCLUSIONS

Prepubertal children on a vegetarian diet had significantly lower total and lumbar spine BMD z-scores, but absolute values of bone mineral density did not differ. BMD z-scores did not correlate with bone metabolism markers and nutritional variables, but were positively associated with anthropometric parameters. Lower leptin levels in vegetarian children reflect lower body fat. Longitudinal studies are necessary to evaluate the impact of the observed association on bone health at adulthood.

Serum Hepcidin and Soluble Transferrin Receptor in the Assessment of Iron Metabolism in Children on a Vegetarian Diet

The aim of this study was to assess the effect of vegetarian diet on iron metabolism parameters paying special attention to serum hepcidin and soluble transferrin receptor (sTfR) concentrations in 43 prepubertal children (age range 4.5-9.0 years) on vegetarian and in 46 children on omnivorous diets. There were no significant differences according to age, weight, height, and body mass index (BMI) between vegetarian and omnivorous children. Vegetarians had similar intake of iron and vitamin B12 and a significantly higher intake of vitamin C (p < 0.05) compared with non-vegetarians. Hematologic parameters and serum iron concentrations were within the reference range in both groups of children. Serum transferrin levels were similar in all subjects; however, ferritin concentrations were significantly (p < 0.01) lower in vegetarians than in omnivores. In children on a vegetarian diet, median hepcidin levels were lower (p < 0.05) but sTfR concentrations significantly higher (p < 0.001) compared with omnivorous children. In the multivariate regression model, we observed associations between hepcidin level and ferritin concentration (β = 0.241, p = 0.05) in the whole group of children as well as between hepcidin concentration and CRP level (β = 0.419, p = 0.047) in vegetarians. We did not find significant associations with concentration of sTfR and selected biochemical, anthropometric, and dietary parameters in any of the studied groups of children. As hematologic parameters and iron concentrations in vegetarians and omnivores were comparable and ferritin level was lower in vegetarians, we suggest that inclusion of novel markers, in particular sTfR (not cofounded by inflammation) and hepcidin, can better detect subclinical iron deficiency in children following vegetarian diets.

Iron Status of Vegetarian Children: A Review of Literature

Background: Iron is considered a nutrient of concern for vegetarians. In children, inadequate iron status may lead to anemia and poor growth. Summary: Thirteen original manuscripts met the inclusion criteria. Various biochemical markers of iron status, such as hemoglobin (Hb) and serum ferritin, were used. Seven of the 13 studies reported the prevalence of iron deficiency separately for vegetarians and non-vegetarians. Five out of 7 showed a higher prevalence of iron deficiency among the vegetarian participants, while the other 2 showed a higher prevalence of iron deficiency among non-vegetarians. A wide range of iron deficiency prevalence, from 4.3% of vegetarian participants in one study to 73% having ferritin <10 µg/L in another study, was found. Hb data showed almost as wide variations from 0% of children having Hb values lower than 11 g/dL to 47.5% having Hb values below 3rd percentile. Key Messages: The prevalence of iron deficiency among vegetarian children varies considerably from one study to another. The wide variation in the prevalence of inadequate iron status was consistent for studies from industrial and developing countries. The physiological significance of low iron status among vegetarians reported in some studies is unknown.

Vegetarian diets in children: a systematic review

PURPOSE

While the prevalence of children on vegetarian diets is assumed to be on the rise in industrialized countries, there are hardly any representative data available. In general, vegetarian diets are presumed to be healthy; nevertheless, there are concerns as to whether the dietary specifications required during infancy, childhood, and adolescence can be met. Therefore, the objective of this systematic review was to evaluate studies on the dietary intake and the nutritional or health status of vegetarian infants, children, and adolescents.

METHODS

The database MEDLINE was used for literature search. In addition, references of reviews and expert opinions were considered. Inclusion criteria were (1) sufficient dietary information to define vegetarian type diet and (2) characteristics of nutritional or health status. Case reports and studies from non-industrialized countries were excluded.

RESULTS

24 publications from 16 studies published from 1988 to 2013 met our criteria. Study samples covered the age range from 0 to 18 years, and median sample size was 35. Five studies did not include a control group. With regard to biomarkers, anthropometry, and dietary or nutritional intake, the outcomes were diverse. Growth and body weight were generally found within the lower reference range. The intakes of folate, vitamin C, and dietary fiber were relatively high compared to reference values and/or control groups. Low status of vitamin B₁₂ was reported in one study and low status of vitamin D in two studies.

CONCLUSIONS

Due to the study heterogeneity, the small samples, the bias towards upper social classes, and the scarcity of recent studies, the existing data do not allow us to draw firm conclusions on health benefits or risks of present-day vegetarian type diets on the nutritional or health status of children and adolescents in industrialized countries.

[Vegetarische und vegane Ernährung bei Kindern - Stand der Forschung und Forschungsbedarf]

Die Praxis vegetarischer Ernährungsformen ist in Deutschland im letzten Jahrzehnt deutlich angestiegen. Allerdings ist der Anteil vegetarischer und veganer Kinder dabei unbekannt. Studien mit Erwachsenen zeigen das präventive Potenzial, aber auch potenzielle Schwachstellen pflanzenbasierter Kostformen. Die Vorteile und Risiken einer vegetarischen bzw. veganen Ernährung im Kindesalter wurden bisher jedoch relativ selten untersucht. Außerdem lassen das unterschiedliche Alter der Kinder, das heterogene Studiendesign sowie die teilweise geringe Probandenzahl der Studien keine verbindlichen Aussagen zu. In dieser Übersichtsarbeit werden die Ergebnisse der wenigen Studien zu vegetarisch und vegan ernährten Kindern (< 12 Jahren) in Nordamerika und Europa zusammengefasst. Demnach lag die Zufuhr von Nahrungsenergie und Makronährstoffen vegetarischer und veganer Kinder meist näher an den Empfehlungen der Fachgesellschaften als die Ernährung gleichaltriger Mischkostkinder. Ebenso wiesen vegetarisch und vegan ernährte Kinder eine höhere Zufuhr von und bessere Versorgung mit verschiedenen Vitaminen und Mineralstoffen auf. Häufiger zeigten sich jedoch Defizite bei Vitamin B12, Zink, Kalzium, Eisen und Vitamin D. Das Wachstum und die Entwicklung vegetarisch und vegan ernährter Kinder entsprachen weitgehend den Referenzstandards, wobei sie dazu tendierten, leichter, schlanker und (< 5 Jahren) auch kleiner zu sein. Aufgrund der unzureichenden Studienlage besteht erheblicher Forschungsbedarf zu den Auswirkungen einer vegetarischen und veganen Ernährung im Kindesalter.

Vegetarian diets across the lifecycle: impact on zinc intake and status

Optimal zinc status is an important consideration when evaluating the nutritional adequacy of vegetarian diets. In the absence of animal tissue sources of zinc and with increased intake of inhibitors of zinc absorption, phytic acid in particular, the bioavailability of zinc is thought to be lower from vegetarian as compared to omnivorous diets. The aim of this chapter is to review the research that examines the effects of vegetarian compared to omnivorous diets on zinc intake and zinc status in the elderly, adults, children, pregnancy, and lactation. A narrative review of the published literature was undertaken, focusing on observational studies in humans that reported zinc intake and biomarkers of zinc status at various stages of the life cycle. Compared to their respective nonvegetarian control groups, adult male and female vegetarians have lower dietary zinc intakes and serum zinc concentrations. However in the elderly, children, and in women during pregnancy and lactation, there is insufficient evidence to determine whether zinc intake and status are lower in vegetarians compared to omnivores. Inconsistencies in study findings reflect variations inherent in the definition of vegetarian diets, and in many instances compromised statistical power due to a small sample size. Improved methods for the assessment of zinc status are required to determine whether homeostatic responses are sufficient to maintain an adequate zinc status in vegetarians, particularly during times of increased requirement. Appropriate dietary advice to increase the zinc content and bioavailability of vegetarian diets throughout the life cycle is prudent.

Intake patterns and dietary associations of soya protein consumption in adults and children in the Canadian Community Health Survey, Cycle 2.2

Soya foods are one of the recommended alternatives to meat in many dietary guidelines. While this is expected to increase the intake of some nutrients, potential concerns regarding others have been raised. The purpose of the present study was to examine the prevalence and the association of soya food consumption with nutrient intakes and dietary patterns of Canadians (age ≥ 2 years). Cross-sectional data from the 2004 Canadian Community Health Survey (Cycle 2.2; n 33 218) were used to classify soya consumers and non-consumers. Soya consumers were further divided into two groups based on their soya protein intake. Sample weights were applied and logistic regression analysis was used to explore the association between nutrient intakes and soya consumption, with cultural background, sex, age and economic status being included as covariates. On any given day, 3·3 % (n 1085) of Canadians consume soya foods, with females, Asian Canadians and adults with post-secondary education being more likely to be soya consumers. As a whole, adolescent and adult respondents who had consumed at least one soya food during their 24 h dietary recall had higher energy intakes, as well as increased intakes of nutrients such as protein, fibre, vitamin C, vitamin B6, naturally occurring folate, thiamin, Ca, P, Mg, PUFA, Fe and K and lowered intakes of saturated fat. These data indicate that soya food consumption is associated with improved diet quality of Canadians. However, future research is necessary to investigate the association between increased energy intake and soya consumption.

Is iron and zinc nutrition a concern for vegetarian infants and young children in industrialized countries?

Well-planned vegetarian diets are considered adequate for all stages of the life cycle, despite limited data on the zinc status of vegetarians during early childhood. The bioavailability of iron and zinc in vegetarian diets is poor because of their higher content of absorption inhibitors such as phytate and polyphenols and the absence of flesh foods. Consequently, children as well as adult vegetarians often have lower serum ferritin concentrations than omnivores, which is indicative of reduced iron stores, despite comparable intakes of total iron; hemoglobin differences are small and rarely associated with anemia. However, data on serum zinc concentrations, the recommended biomarker for identifying population groups at elevated risk of zinc deficiency, are sparse and difficult to interpret because recommended collection and analytic procedures have not always been followed. Existing data indicate no differences in serum zinc or growth between young vegetarian and omnivorous children, although there is some evidence of low serum zinc concentrations in vegetarian adolescents. Some vegetarian immigrants from underprivileged households may be predisposed to iron and zinc deficiency because of nondietary factors such as chronic inflammation, parasitic infections, overweight, and genetic hemoglobin disorders. To reduce the risk of deficiency, the content and bioavailability of iron and zinc should be enhanced in vegetarian diets by consumption of fortified cereals and milk, by consumption of leavened whole grains, by soaking dried legumes before cooking and discarding the soaking water, and by replacing tea and coffee at meals with vitamin C-rich drinks, fruit, or vegetables. Additional recommended practices include using fermented soy foods and sprouting at least some of the legumes consumed. Fortified foods can reduce iron deficiency, but whether they can also reduce zinc deficiency is less certain. Supplements may be necessary for vegetarian children following very restricted vegan diets.

Dietary pattern analysis: a comparison between matched vegetarian and omnivorous subjects

Background

Dietary pattern analysis, based on the concept that foods eaten together are as important as a reductive methodology characterized by a single food or nutrient analysis, has emerged as an alternative approach to study the relation between nutrition and disease. The aim of the present study was to compare nutritional intake and the results of dietary pattern analysis in properly matched vegetarian and omnivorous subjects.

Methods

Vegetarians (n = 69) were recruited via purposeful sampling and matched non-vegetarians (n = 69) with same age, gender, health and lifestyle characteristics were searched for via convenience sampling. Two dietary pattern analysis methods, the Healthy Eating Index-2010 (HEI-2010) and the Mediterranean Diet Score (MDS) were calculated and analysed in function of the nutrient intake.

Results

Mean total energy intake was comparable between vegetarians and omnivorous subjects (p > 0.05). Macronutrient analysis revealed significant differences between the mean values for vegetarians and omnivorous subjects (absolute and relative protein and total fat intake were significantly lower in vegetarians, while carbohydrate and fibre intakes were significantly higher in vegetarians than in omnivorous subjects). The HEI and MDS were significantly higher for the vegetarians (HEI = 53.8.1 ± 11.2; MDS = 4.3 ± 1.3) compared to the omnivorous subjects (HEI = 46.4 ± 15.3; MDS = 3.8 ± 1.4).

Conclusions

Our results indicate a more nutrient dense pattern, closer to the current dietary recommendations for the vegetarians compared to the omnivorous subjects. Both indexing systems were able to discriminate between the vegetarians and the non-vegetarians with higher scores for the vegetarian subjects.

Iron status and dietary iron intake of vegetarian children from Poland

BACKGROUND/AIM

In Poland, vegetarian diets are becoming more and more popular. The aim of this study was to examine the effect of iron intake on iron status in vegetarian children.

METHODS

Dietary iron intake, iron food sources, blood count, serum iron, ferritin level and total iron-binding capacity were estimated in two groups of children, namely vegetarians (n = 22) and omnivores (n = 18) of both sexes, aged from 2 to 18 years. Seven-day food records were used to assess their diet.

RESULTS

Dietary iron intake in vegetarians and omnivores was low (up to 65.0 and 60.1% of the recommended dietary allowance). A significantly higher intake of vitamin C was observed in vegetarians compared with omnivores (p = 0.019). The main sources of iron in vegetarians were cereal products, followed by vegetables and mushroom products, then fruit. The prevalence of iron deficiency (ID) was higher in the vegetarian group (p = 0.023). The serum ferritin level and mean corpuscular volume in the vegetarians were also lower than in the omnivores (p = 0.01 and p = 0.014, respectively).

CONCLUSIONS

Children who follow a vegetarian diet may suffer from ID in spite of having a high vitamin C intake. This indicates the need to introduce dietary education and iron status monitoring.

Clinical practice: vegetarian infant and child nutrition

The aim of this review is to give insight on the benefits and risks of vegetarianism, with special emphasis on vegetarian child nutrition. This eating pattern excluding meat and fish is being adopted by a growing number of people. A vegetarian diet has been shown to be associated with lower mortality of ischaemic heart disease and lower prevalence of obesity. Growth in children on a vegetarian diet including dairy has been shown to be similar to omnivorous peers. Although vegetarianism in adolescents is associated with eating disorders, there is no proof of a causal relation, as the eating disorder generally precedes the exclusion of meat from the diet. A well-balanced lacto-ovo-vegetarian diet, including dairy products, can satisfy all nutritional needs of the growing child. In contrast, a vegan diet, excluding all animal food sources, has at least to be supplemented with vitamin B(12), with special attention to adequate intakes of calcium and zinc and energy-dense foods containing enough high-quality protein for young children. The more restricted the diet and the younger the child, the greater the risk for deficiencies.

Health aspects, nutrition and physical characteristics in matched samples of institutionalized vegetarian and non-vegetarian elderly (> 65yrs)

Background

Epidemiological studies indicate that a well balanced vegetarian diet offers several health benefits including a lower prevalence of prosperity diseases in vegetarians compared to omnivores. It was the purpose of the present study to compare nutritional and physical characteristics in matched samples of institutionalized vegetarian (V) and non-vegetarian (NV) elderly.

Methods

Twenty-two female and 7 male V (females: 84.1 ± 5.1yrs, males: 80.5 ± 7.5yrs) and 23 female and 7 male NV (females: 84.3 ± 5.0yrs, males: 80.6 ± 7.3yrs) participated. All subjects were over 65 years of age, and free of major disease or physical handicap. Dietary intake, blood profile, anthropometrics, and handgrip strength were determined.

Results

Mean daily energy intake was 6.8 ± 2.0MJ in V females, and 8.0 ± 1.4MJ in the NV females, only the V did not reach the recommended value of 7.8 MJ. Male V and NV had a mean daily energy intake of 8.7 ± 1.6MJ and 8.7 ± 1.2MJ respectively (RDI: 8.8 MJ). Mean carbohydrate intake was significantly below the RDI in NV only (female V: 47.8 ± 7.5E%, female NV: 43.3 ± 4.6E%, male V: 48.1 ± 6.4E%, male NV: 42.3 ± 3.6E%), while protein (female V: 17.3 ± 3.4E%, female NV: 19.5 ± 3.5E%, male V: 17.8 ± 3.4E%, male NV: 21.0 ± 2.0E%), and saturated fat intake (female V: 25.4 ± 8.2 g/day, female NV: 32.2 ± 6.9 g/day, male V: 31.4 ± 12.9 g/day, male NV: 33.4 ± 4.7 g/day) were too high in both V and NV. Mean micronutrient intakes met the RDI's in all 4 groups. Mean blood concentrations for vitamin B12, folic acid, iron, and calcium were normal in all 4 groups. Mean zinc blood serum was below the reference value in all groups, whereas estimated zinc intake was in agreement with the RDI. The mean blood cholesterol concentration was above the 200 mg/dl upper limit in the V group (213 ± 40 mg/dl) and below that limit in the NV (188 ± 33 mg/dl) group. Mean BMI was 26.1 ± 4.7 kg/m² in the female V, 26.8 ± 3.7 kg/m² in the female NV, 23.5 ± 3.7 kg/m² in the male V, and 25.2 ± 4.2 kg/m² in the male NV. V and NV scored below the reference values for the handgrip strength test.

Conclusions

Generally, our results show a similar profile for V and NV concerning dietary intake, blood values, and physical characteristics. Attention should be paid to the intake of mono- and disaccharides and saturated fats in the diet of both V and NV. This study indicates that a vegetarian lifestyle has no negative impact on the health status at older age.

Nutritional intake of various groups of Flemish vegetarians

Background

Objective

Materials and methods

Results

Conclusions

An impact of the diet on serum fatty acid and lipid profiles in Polish vegetarian children and children with allergy

BACKGROUND/OBJECTIVES

Vegetarian diet has become an increasing trend in western world and in Poland. The frequency of allergies is growing, and the effectiveness of vegetarian diet in allergic diseases is a concern for research. We aimed to study an effect of vegetarian diet on lipid profile in serum in a group of Polish children in Poland and to investigate lipid parameters in healthy vegetarian children and in omnivorous children with diagnosed atopic disease.

SUBJECTS/METHODS

Serum lipid profiles (triglycerides, total cholesterol, low-density lipoprotein (LDL) and high-density lipoprotein (HDL) cholesterol, fatty acids) were assessed in groups of children: healthy vegetarians (n=24) and children with diagnosed atopic diseases (n=16), with control group of healthy omnivores (n=18). Diet classification was assessed by a questionnaire.

RESULTS

No differences were observed in serum triglycerides, LDL cholesterol and saturated and monounsaturated fatty acids level in all groups. In the group of Polish vegetarian children, we recorded high consumption of vegetable oils rich in monounsaturated fatty acid, and sunflower oil containing linoleic acid. This observation was associated with higher content of linoleic acid in serum in this group. Among polyunsaturated n-6 fatty acids, linoleic acid revealed significantly (P<0.05) lower levels in allergy vs vegetarian groups. In case of eicosapentaenoic acid (n-3 fatty acid), the allergy group showed higher levels of this compound in comparison to vegetarians.

CONCLUSIONS

Significantly higher concentration of linoleic acid in vegetarian children in comparison to allergy group indicated possible alternative path of lipid metabolism in studied groups, and in consequence, some elements of vegetarian diet may promote protection against allergy.

Nutritional status of Flemish vegetarians compared with non-vegetarians: a matched samples study

The present study compares the nutritional status of vegetarian (V) with non-vegetarian (NV) subjects. A three-day food record and a health questionnaire were completed by 106 V and 106 NV matched for following characteristics: sex, age, BMI, physical activity, tobacco use and alcohol consumption. Total energy intake was not significantly different (men: V: 2,346 ± 685 kcal/d; NV: 2,628 ± 632 kcal/d; p = 0.078; women: V: 1,991 ± 539 kcal/d; NV: 1,973 ± 592 kcal/d; p = 0.849). Macronutrients intake differed significantly between the V and NV subjects for protein (men: V:12.7 ± 2.3 E%; NV:15.3 ± 4.5 E%; p = 0.003; women: V: 13.2 ± 2.3 E%; NV:16.0 ± 4.0 E%; p < 0.001), fat (men: V: 29.3 ± 8.4 E%; NV: 33.8 ± 5.3 E%; p = 0.010; women: V: 29.7 ± 6.9 E%; NV: 34.7 ± 9.0 E%; p < 0.001), and carbohydrate (men: V: 55.3 ± 10.1 E%; NV: 47.4 ± 6.9 E%; p < 0.001; women: V: 55.1 ± 7.6 E%; NV: 47.2 ± 8.2 E%; p < 0.001). The intake of most minerals was significantly different between the V and the NV subjects. V had a lower sodium intake, higher calcium, zinc, and iron intake compared to the NV subjects. Our results clearly indicate that a vegetarian diet can be adequate to sustain the nutritional demands to at least the same degree as that of omnivores. The intakes of the V subjects were closer to the recommendations for a healthy diet when compared to a group of well matched NV subjects.

Plenary Lecture 3: Food and the planet: nutritional dilemmas of greenhouse gas emission reductions through reduced intakes of meat and dairy foods

Legally-binding legislation is now in place to ensure major reductions in greenhouse gas emissions in the UK. Reductions in intakes of meat and dairy products, which account for approximately 40% of food-related emissions, are an inevitable policy option. The present paper assesses, as far as is possible, the risk to nutritional status of such a policy in the context of the part played by these foods in overall health and well-being and their contribution to nutritional status for the major nutrients that they supply. Although meat may contribute to saturated fat intakes and a higher BMI, moderate meat consumption within generally-healthy population groups has no measurable influence on morbidity or mortality. However, high consumption of red and processed meat has been associated with increased risk of colo-rectal cancer and recent advice is to reduce intakes to a maximum of 70 g/d. Such reductions in meat and haem-Fe intake are unlikely to influence Fe status in functional terms. However, overall protein intakes would probably fall, with the potential for intakes to be less than current requirements for the elderly. Whether it is detrimental to health is uncertain and controversial. Zn intakes are also likely to fall, raising questions about child growth that are currently unanswerable. Milk and dairy products, currently specifically recommended for young children and pregnant women, provide 30-40% of dietary Ca, iodine, vitamin B12 and riboflavin. Population groups with low milk intakes generally show low intakes and poor status for each of these nutrients. Taken together it would appear that the reductions in meat and dairy foods, which are necessary to limit environmental damage, do pose serious nutritional challenges for some key nutrients. These challenges can be met, however, by improved public health advice on alternative dietary sources and by increasing food fortification.

Soybean ferritin: implications for iron status of vegetarians

Meeting the requirement for absorbed iron is difficult for vegetarians, and their iron status often is lower than that of nonvegetarians. Beans contain ferritin in low concentrations, but it is possible to enhance this content by plant breeding or by inserting the gene for ferritin into plants, eg, soybeans. Because each ferritin molecule can bind to thousands of iron atoms, this may be a sustainable means to increase the iron contents of plants. Before such efforts are launched, it is important to determine whether iron in ferritin is bioavailable. This has been assessed in vitro by using human intestinal (Caco-2) cells and in vivo by using radiolabeled ferritin and whole-body counting in human subjects. Dietary factors affecting iron absorption, eg, ascorbic acid, phytate, and calcium, had limited effect on iron uptake from intact ferritin by Caco-2 cells, which suggests that ferritin-bound iron is absorbed via a mechanism different from that of nonheme iron. In an in vitro digestion system, ferritin was shown to be relatively resistant to proteolytic enzymes. Binding of ferritin to Caco-2 cells was shown to be saturable, and the kinetics for binding were characteristic of a receptor-mediated process. In human subjects, iron from purified soybean ferritin given in a meal was as well absorbed as iron from ferrous sulfate. In conclusion, iron is well absorbed from ferritin and may represent a means of biofortification of staple foods such as soybeans.

Impact of menstrual blood loss and diet on iron deficiency among women in the UK

Women of childbearing age are at risk of Fe deficiency if insufficient dietary Fe is available to replace menstrual and other Fe losses. Haem Fe represents 10–15 % of dietary Fe intake in meat-rich diets but may contribute 40 % of the total absorbed Fe. The aim of the present study was to determine the relative effects of type of diet and menstrual Fe loss on Fe status in women. Ninety healthy premenopausal women were recruited according to their habitual diet: red meat, poultry/fish or lacto-ovo-vegetarian. Intake of Fe was determined by analysing 7 d duplicate diets, and menstrual Fe loss was measured using the alkaline haematin method. A substantial proportion of women (60 % red meat, 40 % lacto-ovo-vegetarian, 20 % poultry/fish) had low Fe stores (serum ferritin <10 μg/l), but the median serum ferritin concentration was significantly lower in the red meat group (6·8 μg/l (interquartile range 3·3, 16·25)) than in the poultry/fish group (17·5 μg/l (interquartile range 11·3, 22·4) (P<0·01). The mean and standard deviation of dietary Fe intake were significantly different between the groups (P=0·025); the red meat group had a significantly lower intake (10·9 (sd 4·3) mg/d) than the lacto-ovo-vegetarians (14·5 (sd 5·5) mg/d), whereas that of the poultry/fish group (12·8 (sd 5·1) mg/d) was not significantly different from the other groups. There was no relationship between total Fe intake and Fe status, but menstrual Fe loss (P=0·001) and dietary group (P=0·040) were significant predictors of Fe status: poultry/fish diets were associated with higher Fe stores than lacto-ovo-vegetarian diets. Identifying individuals with high menstrual losses should be a key component of strategies to prevent Fe deficiency.

Effect of changing to a self-selected vegetarian diet on anthropometric measurements in UK adults

BACKGROUND

Vegetarians are often a little leaner compared with nonvegetarians and suffer less from obesity and its associated complications than nonvegetarians. Whether this is because of not eating meat specifically is unclear.

OBJECTIVE

We investigated whether changing to a self-selected vegetarian diet resulted in changes to anthropometric measurements. Design Subjects (n = 33; seven males and 26 females) who were in the earliest stages of becoming vegetarian were observed for 6 months. Data on dietary intake, using a 3-day estimated dietary diary, and body composition were obtained at baseline and after 6 months of following a self-selected vegetarian diet.

RESULTS

Dietary calculations showed that on changing to a self-selected vegetarian diet, there was a significant reduction (P < 0.05) in energy intake (8.9 MJ day(-1) versus 8.1 MJ day(-1)), and in the proportion of energy from saturated fatty acids (12.9% versus 11.3%) and a significant increase (P < 0.05) in the proportion of energy from carbohydrates (44.9% versus 47.5%) and in intake of nonstarch polysaccharides (NSP) (1.6 g MJ(-1) versus 2.0 g MJ(-1)). Significant reductions in mid-upper arm circumference, calculated body fat, biceps and triceps skinfolds and waist and hip circumferences were observed. No reduction in body weight was observed.

CONCLUSION

The findings of our study suggest that significant dietary changes, helping people to conform more closely to current dietary recommendations, occurred when people became vegetarian. In this study we did not find any significant change in body weight, but significant reductions were observed in skinfold thickness and waist : height ratio which imply that on changing to a self-selected vegetarian diet, the subjects became leaner.

Vitamin B12 deficiency as a worldwide problem

Pernicious anemia is a common cause of megaloblastic anemia throughout the world and especially in persons of European or African descent. Dietary deficiency of vitamin B12 due to vegetarianism is increasing and causes hyperhomocysteinemia. The breast-fed infant of a vitamin B12-deficient mother is at risk for severe developmental abnormalities, growth failure, and anemia. Elevated methylmalonic acid and/or total homocysteine are sensitive indicators of vitamin B12-deficient diets and correlate with clinical abnormalities. Dietary vitamin B12 deficiency is a severe problem in the Indian subcontinent, Mexico, Central and South America, and selected areas in Africa. Dietary vitamin B12 deficiency is not prevalent in Asia, except in vegetarians. Areas for research include intermittent vitamin B12 supplement dosing and better measurements of the bioavailability of B12 in fermented vegetarian foods and algae.

Bioavailability of iron, zinc, and other trace minerals from vegetarian diets

Iron and zinc are currently the trace minerals of greatest concern when considering the nutritional value of vegetarian diets. With elimination of meat and increased intake of phytate-containing legumes and whole grains, the absorption of both iron and zinc is lower with vegetarian than with nonvegetarian, diets. The health consequences of lower iron and zinc bioavailability are not clear, especially in industrialized countries with abundant, varied food supplies, where nutrition and health research has generally supported recommendations to reduce meat and increase legume and whole-grain consumption. Although it is clear that vegetarians have lower iron stores, adverse health effects from lower iron and zinc absorption have not been demonstrated with varied vegetarian diets in developed countries, and moderately lower iron stores have even been hypothesized to reduce the risk of chronic diseases. Premenopausal women cannot easily achieve recommended iron intakes, as modified for vegetarians, with foods alone; however, the benefit of routine iron supplementation has not been demonstrated. It may be prudent to monitor the hemoglobin of vegetarian children and women of childbearing age. Improved assessment methods are required to determine whether vegetarians are at risk of zinc deficiency. In contrast with iron and zinc, elements such as copper appear to be adequately provided by vegetarian diets. Although the iron and zinc deficiencies commonly associated with plant-based diets in impoverished nations are not associated with vegetarian diets in wealthier countries, these nutrients warrant attention as nutritional assessment methods become more sensitive and plant-based diets receive greater emphasis.

Risk factors for low iron intake and poor iron status in a national sample of British young people aged 4-18 years

OBJECTIVE

To examine the prevalence and dietary, sociodemographic and lifestyle risk factors of low iron intake and poor iron status in British young people.

DESIGN

National Diet and Nutrition Survey of young people aged 4-18 years.

SETTING

Great Britain, 1997.

SUBJECTS

In total, 1699 young people provided 7-day weighed dietary records, of which 11% were excluded because the participant reported being unwell with eating habits affected. Blood was obtained from 1193 participants, with iron status indicated by haemoglobin, serum ferritin and transferrin saturation.

RESULTS

Iron intakes were generally adequate in most young people aged 4-18 years. However, low iron intakes (below the Lower Reference Nutrient Intake) occurred in 44% of adolescent girls (11-18 years), being less prevalent with high consumption of breakfast cereals. Low haemoglobin concentration (<115 g l-1, 4-12 years; <120 or <130 g l-1, 13+ years for girls and boys, respectively) was observed in 9% of children aged 4-6 years, pubertal boys (11-14 years) and older girls (15-18 years). Adolescent girls who were non-Caucasians or vegetarians had significantly poorer iron status than Caucasians or meat eaters, independent of other risk factors. The three iron status indices were correlated significantly with haem, but not non-haem, iron intake.

CONCLUSIONS

Adolescent girls showed the highest prevalence of low iron intake and poor iron status, with the latter independently associated with non-Caucasian ethnicity and vegetarianism. Risk of poor iron status may be reduced by consuming (particularly lean red) meat or enhancers of non-haem iron absorption (e.g. fruit or fruit juice) in vegetarians.

Position of the American Dietetic Association and Dietitians of Canada: vegetarian diets

It is the position of the American Dietetic Association and Dietitians of Canada that appropriately planned vegetarian diets are healthful, nutritionally adequate, and provide health benefits in the prevention and treatment of certain diseases. Approximately 2.5% of adults in the United States and 4% of adults in Canada follow vegetarian diets. A vegetarian diet is defined as one that does not include meat, fish, or fowl. Interest in vegetarianism appears to be increasing, with many restaurants and college foodservices offering vegetarian meals routinely. Substantial growth in sales of foods attractive to vegetarians has occurred and these foods appear in many supermarkets. This position paper reviews the current scientific data related to key nutrients for vegetarians including protein, iron, zinc, calcium, vitamin D, riboflavin, vitamin B-12, vitamin A, n-3 fatty acids, and iodine. A vegetarian, including vegan, diet can meet current recommendations for all of these nutrients. In some cases, use of fortified foods or supplements can be helpful in meeting recommendations for individual nutrients. Well-planned vegan and other types of vegetarian diets are appropriate for all stages of the life-cycle including during pregnancy, lactation, infancy, childhood, and adolescence. Vegetarian diets offer a number of nutritional benefits including lower levels of saturated fat, cholesterol, and animal protein as well as higher levels of carbohydrates, fibre, magnesium, potassium, folate, antioxidants such as vitamins C and E, and phytochemicals. Vegetarians have been reported to have lower body mass indices than non-vegetarians, as well as lower rates of death from ischemic heart disease, lower blood cholesterol levels, lower blood pressure, and lower rates of hypertension, type 2 diabetes, and prostate and colon cancer. While a number of federally funded and institutional feeding programs can accommodate vegetarians, few have foods suitable for vegans at this time. Because of the variability of dietary practices among vegetarians, individual assessment of dietary intakes of vegetarians is required. Dietetics professionals have a responsibility to support and encourage those who express an interest in consuming a vegetarian diet. They can play key roles in educating vegetarian clients about food sources of specific nutrients, food purchase and preparation, and any dietary modifications that may be necessary to meet individual needs. Menu planning for vegetarians can be simplified by use of a food guide that specifies food groups and serving sizes.

The association between red and processed meat consumption and iron intakes and status among British adults

OBJECTIVE

To examine the association between consumption of red and processed meat (RPM) and iron intakes and status in adults.

DESIGN

Further analysis of the Dietary and Nutritional Survey of British Adults, a cross-sectional study of 2197 adults aged 16-64 years carried out in 1986/7.

SUBJECTS AND METHODS

Adults (836 men and 838 women) with serum ferritin measurements, who were not taking iron supplements, were classified into four groups according to RPM consumption (from 7-day weighed records). Iron absorbed was estimated from equations based on haem and non-haem iron and the influence of iron stores.

RESULTS

Women who ate least meat (<90 g day-1) had three times the risk of a low iron intake (below the Lower Reference Nutrient Intake) compared with high consumers of RPM (>140 g day-1). Men who ate no RPM also had a higher risk of low iron intake. Using an estimate of minimal values for iron losses, there was a twofold difference in the potential risk of negative iron balance between women non-RPM consumers and high RPM consumers. Status measurements indicated that, among women, anaemia was least prevalent (6%) among high consumers compared with 12-14% among average RPM consumers. Inverse trends were also observed for serum ferritin in both sexes.

CONCLUSIONS

Low consumption of RPM has implications for iron intakes and iron status in men and women, since the risk of negative iron balance and its consequences are increased. Dietary messages must consider these implications and provide appropriate advice.

Position of the American Dietetic Association and Dietitians of Canada: Vegetarian diets

It is the position of the American Dietetic Association and Dietitians of Canada that appropriately planned vegetarian diets are healthful, nutritionally adequate, and provide health benefits in the prevention and treatment of certain diseases. Approximately 2.5% of adults in the United States and 4% of adults in Canada follow vegetarian diets. A vegetarian diet is defined as one that does not include meat, fish, or fowl. Interest in vegetarianism appears to be increasing, with many restaurants and college foodservices offering vegetarian meals routinely. Substantial growth in sales of foods attractive to vegetarians has occurred, and these foods appear in many supermarkets. This position paper reviews the current scientific data related to key nutrients for vegetarians, including protein, iron, zinc, calcium, vitamin D, riboflavin, vitamin B-12, vitamin A, n-3 fatty acids, and iodine. A vegetarian, including vegan, diet can meet current recommendations for all of these nutrients. In some cases, use of fortified foods or supplements can be helpful in meeting recommendations for individual nutrients. Well-planned vegan and other types of vegetarian diets are appropriate for all stages of the life cycle, including during pregnancy, lactation, infancy, childhood, and adolescence. Vegetarian diets offer a number of nutritional benefits, including lower levels of saturated fat, cholesterol, and animal protein as well as higher levels of carbohydrates, fiber, magnesium, potassium, folate, and antioxidants such as vitamins C and E and phytochemicals. Vegetarians have been reported to have lower body mass indices than nonvegetarians, as well as lower rates of death from ischemic heart disease; vegetarians also show lower blood cholesterol levels; lower blood pressure; and lower rates of hypertension, type 2 diabetes, and prostate and colon cancer. Although a number of federally funded and institutional feeding programs can accommodate vegetarians, few have foods suitable for vegans at this time. Because of the variability of dietary practices among vegetarians, individual assessment of dietary intakes of vegetarians is required. Dietetics professionals have a responsibility to support and encourage those who express an interest in consuming a vegetarian diet. They can play key roles in educating vegetarian clients about food sources of specific nutrients, food purchase and preparation, and any dietary modifications that may be necessary to meet individual needs. Menu planning for vegetarians can be simplified by use of a food guide that specifies food groups and serving sizes.

An investigation of the validity and reliability of a food intake questionnaire

AIMS

To evaluate the reliability and criterion validity of a food intake questionnaire (FIQ) designed for use in schoolchildren.

METHODS

Study of reliability: 98 young people aged 13-14 years attending two schools in deprived areas of Liverpool completed the FIQ on three separate occasions over a 3-month period. VALIDITY STUDY: Ninety-six young people (aged 11-13 years) completed the FIQ and 2 weeks later completed a 3-day food diary (with interview).

RESULTS

The FIQ gave consistent response on separate occasions over the 3-month reliability study period. Levels of agreement were consistent between survey combinations. Analysis of variance showed no differences in mean score for food groups between surveys. Pearson correlations for mean scores estimated by separate FIQ ranged from 0.42 for fibre food group to 0.76 for negative marker food group; the majority of the correlations were above 0.5. The data suggested the FIQ should be able to detect a change of +/-10% in eating habits. The validity study provided modest but significant Pearson correlations between energy intake, fat intake as a percentage of energy intake and sugars intake derived from 3-day diaries, and mean scores for the fatty, sugary and negative marker food group assessed by the FIQ.

CONCLUSIONS

The results from both studies provide an indication of the FIQ's reliability, and suggest it has criterion validity for fatty and sugary and negative marker foods.

A reassessment of the fat intake of children from meat and meat products and an estimate of haem iron intakes

BACKGROUND

It is possible that fat intake from red meat has declined as a consequence of changes in animal husbandry and butchery practices. In particular, a study of the intake of vegetarian and meat-eating children concluded that their fat intakes were similar, but the most recent information on the fat content of meat was not available. In addition, iron availability is probably as important as the total amount of iron consumed but estimates of haem iron intake are rarely made.

METHODS

The dietary intake of 50 omnivorous children was reanalysed to produce new estimates of fat and haem iron intakes. Fat intake from meat and meat products only was recalculated using supplements to the food tables not available to the initial survey. Haem iron intake was calculated by discriminating between the different types of meat consumed and estimates of the proportion of iron which is in the haem form.

RESULTS

The recalculated diets had significantly lower energy (8.03-7.50 MJ), fat (79-73 g) and carbohydrate (257-237 g) levels. The proportions of energy from fat (36%) and carbohydrate (51%) were unaffected. Meat supplied 3.2 mg (33%) of the iron intake (9.6 mg) of which 1.3-1.5 mg (13-16% of the total) was estimated to be in the haem form. Children may be relatively unaffected by the changes in the composition of meat as such, if they consume highly processed foods which include, for example, rusk, pastry, breadcrumbs and batter.

CONCLUSIONS

The original estimates of the intake of fat of these omnivorous children from meat and meat products do appear to have been overestimates, but only as the weight of fat consumed not as a percentage of energy. Haem iron was found to supply a substantial proportion of the iron intake of these children and may account for their higher haemoglobin values.

Dietary intakes and nutrient status of vegetarian preschool children from a British national survey

BACKGROUND: Dietary intakes and nutrient status were compared in meat-eaters and non-meat-eaters from the National Diet and Nutrition Survey of children aged 1.5-4.5 years. METHODS: Children (n = 1351) were categorized as 'omnivores' or 'vegetarians', according to whether they consumed meat or meat products during a 4-day dietary record. Blood samples were also obtained for analysis of haematological and biochemical nutrient status. RESULTS: Three per cent of children were 'vegetarian'. They consumed higher proportions of milk and milk products, although this was significant only in older children (P = 0.007), owing to high consumption by the high proportion of Asian children. In vegetarians, energy intakes tended to be lower in both age groups. Percentage energy from protein and fat were lower, while that from carbohydrate was higher compared with omnivores. Cholesterol intakes were lower, significantly so for younger children (P < 0.001). Intakes of micronutrients were either higher (vitamins C and E, potassium) or lower (niacin and sodium) in younger vegetarians compared with omnivores. Energy-adjusted intakes of iron and zinc did not differ significantly from those of omnivores, although both intakes were low in many children (6-20% < LRNI), particularly in the younger group. Haematological and biochemical nutrient status indices showed few differences. Serum ferritin was lower in vegetarians, significantly so in younger children (P = 0.002). Antioxidant vitamin (A, C and E) status tended to be higher in vegetarians, while vitamin B12 intakes and status were more than adequate. Apart from poorer vitamin D intake and status in older Asian vegetarians, very few ethnic differences were observed. CONCLUSIONS: Nutrient intakes and status were generally adequate in preschool children who did not eat meat. Although serum ferritin levels were inferior (particularly in vegetarians under 3 years old), the lower intakes of fat, cholesterol and sodium, and higher antioxidant vitamin intakes and status indices were potentially beneficial. Given a balanced diet, adequate nutrient intakes and status can be maintained without consuming meat.

Physical fitness and vegetarian diets: is there a relation?

The available evidence supports neither a beneficial nor a detrimental effect of a vegetarian diet on physical performance capacity, especially when carbohydrate intake is controlled for. Concerns have been raised that an emphasis on plant foods to enhance carbohydrate intake and optimize body glycogen stores may lead to increases in dietary fiber and phytic acid intake to concentrations that reduce the bioavailability of several nutrients, including zinc, iron, and some other trace minerals. There is no convincing evidence, however, that vegetarian athletes suffer impaired nutrient status from the interactive effect of their heavy exertion and plant-food based dietary practices to the extent that performance, health, or both are impaired. Although there has been some concern about protein intake for vegetarian athletes, data indicate that all essential and nonessential amino acids can be supplied by plant food sources alone as long as a variety of foods is consumed and the energy intake is adequate. There has been some concern that vegetarian female athletes are at increased risk for oligoamenorrhea, but evidence suggests that low energy intake, not dietary quality, is the major cause. In conclusion, a vegetarian diet per se is not associated with improved aerobic endurance performance. Although some concerns have been raised about the nutrient status of vegetarian athletes, a varied and well-planned vegetarian diet is compatible with successful athletic endeavor.

The nutritional adequacy of plant-based diets

The nutritional adequacy of plant-based diets is discussed. Energy and protein intakes are similar for plant-based diets compared with those containing meat. Fe and vitamin B12 are the nutrients most likely to be found lacking in such diets. Bioactive substances present in foods of plant origin significantly influence the bioavailability of minerals and requirements for vitamins. Well-balanced vegetarian diets are able to support normal growth and development. It is concluded that meat is an optional rather than an essential constituent of human diets.

Is a vegetarian diet adequate for children

The number of people who avoid eating meat is growing, especially among young people. Benefits to health from a vegetarian diet have been reported in adults but it is not clear to what extent these benefits are due to diet or to other aspects of lifestyles. In children concern has been expressed concerning the adequacy of vegetarian diets especially with regard to growth. The risks/benefits seem to be related to the degree of restriction of he diet; anaemia is probably both the main and the most serious risk but this also applies to omnivores. Vegan diets are more likely to be associated with malnutrition, especially if the diets are the result of authoritarian dogma. Overall, lacto-ovo-vegetarian children consume diets closer to recommendations than omnivores and their pre-pubertal growth is at least as good. The simplest strategy when becoming vegetarian may involve reliance on vegetarian convenience foods which are not necessarily superior in nutritional composition. The vegetarian sector of the food industry could do more to produce foods closer to recommendations. Vegetarian diets can be, but are not necessarily, adequate for children, providing vigilance is maintained, particularly to ensure variety. Identical comments apply to omnivorous diets. Three threats to the diet of children are too much reliance on convenience foods, lack of variety and lack of exercise.